At Synergy Orthopedics, we know that insurance and medical billing can sometimes feel confusing. Our goal is to make the process as simple and transparent as possible, so you know what to expect before, during, and after receiving your orthopedic brace or durable medical equipment (DMEPOSupplies).
As a patient-care and third-party billing company, we manage the insurance billing process. While our clinical team is providing the best possible care in the DMEPOS market space, our billing team works directly with your insurance company whenever possible, and we’re here to answer questions along the way.
We Bill Your Insurance
Synergy Orthopedics submits claims directly to Medicare, Medicaid (when applicable), and most commercial insurance plans.
Coverage for orthopedic braces and durable medical equipment varies by insurance plan. While many plans provide coverage for physician-prescribed braces, every policy has different benefits, deductibles, copays, coinsurance requirements, and medical necessity guidelines.
Additionally, every insurance company has its own medical policies that determine whether a service or treatment is covered. Our team carefully reviews the documentation provided by your physician and compares it to your insurance company’s coverage guidelines. If additional information is needed, we will work with your provider to obtain the necessary documentation and do our best to meet the insurer’s requirements.
In some cases, however, the insurance company’s medical criteria cannot be met. If that happens, our team will discuss available self-pay options with you. Because each insurance plan is unique, we encourage patients to contact their insurance provider if they have questions regarding their coverage or anticipated out-of-pocket costs.
How Our Billing Process Works
Every patient’s billing process begins with a prescription from their healthcare provider, but the next steps depend on how the brace is provided. In some cases, your provider prescribed a brace that is ordered through Synergy Orthopedics, and our team communicates with you and schedules your fitting once the device is received. In other cases, your provider has the brace available in the office and fits it during your appointment. While these two scenarios follow slightly different workflows, both ultimately result in your insurance claim being submitted and processed by our billing team.
Your provider prescribed a brace.
Your physician or healthcare provider determines that an orthopedic brace or durable medical equipment (DME) is medically appropriate for your condition.
Brace is Dispensed by Your Provider
Brace is Ordered Through Synergy
The brace is fitted by provider, you sign the PPA, you go home with the brace.
Your healthcare provider fits your brace during your visit. Before leaving, you’ll signs the Patient Product Agreement (PPA) acknowledging receipt of the device, and you’ll go home with your brace the same day.
Prescription and all necessary documentation is sent to Synergy.
Your healthcare provider sends your prescription and any required clinical documentation to Synergy Orthopedics so our team can begin processing your order. Please allow our representatives 24-48 hours to get in touch with you regarding your order.
The brace is fitted by provider, you sign the PPA, you go home with the brace.
Your healthcare provider fits your brace during your visit. Before leaving, you’ll signs the Patient Product Agreement (PPA) acknowledging receipt of the device, and you’ll go home with your brace the same day.
Prescription and all necessary documentation is sent to Synergy.
Your healthcare provider sends your prescription and any required clinical documentation to Synergy Orthopedics so our team can begin processing your order. Please allow our representatives 24-48 hours to get in touch with you regarding your order.
Our team retrieves the PPA and all necessary documentation.
After your visit, our team retrieves the signed PPA and all additional documentation needed to process your insurance claim.
Synergy reviews paperwork and obtains authorization, if needed.
Our team carefully reviews your paperwork to ensure all required documentation has been received. If your insurance requires prior authorization, we work with you, your provider and insurance carrier to obtain approval before moving forward.
Our team retrieves the PPA and all necessary documentation.
After your visit, our team retrieves the signed PPA and all additional documentation needed to process your insurance claim.
Synergy reviews paperwork and obtains authorization, if needed.
Our team carefully reviews your paperwork to ensure all required documentation has been received. If your insurance requires prior authorization, we work with you, your provider and insurance carrier to obtain approval before moving forward.
Our team submits the insurance claim
Once all required documentation has been collected and reviewed, our billing team submits your insurance claim to your insurance company using the appropriate Healthcare Common Procedure Coding System (HCPCS) billing code. (To learn more about HCPCS codes, click here)
Brace is ordered and fitted by Synergy representative and the insurance claim is submitted.
Once any necessary authorization has been obtained, your brace is ordered and fitted by a Synergy Orthopedics representative. After your brace has been dispenses, we submit your insurance claim for processing.
Our team submits the insurance claim
Once all required documentation has been collected and reviewed, our billing team submits your insurance claim to your insurance company using the appropriate Healthcare Common Procedure Coding System (HCPCS) billing code. (To learn more about HCPCS codes, click here)
Brace is ordered and fitted by Synergy representative and the insurance claim is submitted.
Once any necessary authorization has been obtained, your brace is ordered and fitted by a Synergy Orthopedics representative. After your brace has been dispenses, we submit your insurance claim for processing.
Insurance Review
Your insurance company reviews the claim based on your individual benefits, medical necessity requirements, and your plan’s coverage. This review determines the amount your insurance will pay toward your brace.
Insurance Payment
If your claim is approved, your insurance company pays its covered portion directly to Synergy Orthopedics.
Patient Responsibility
After your insurance has processed the claim, you may receive a statement for any remaining balance. Depending on your insurance plan, this may include:
- Deductibles
- Copayments
- Coinsurance
- Non-covered services or products
- Any remaining balance determined by your insurance company
Understanding Your Out-of-Pocket Costs
Your final patient responsibility depends entirely on your individual insurance benefits.
Deductible
A deductible is the amount you must pay for covered healthcare services before your insurance plan beings paying. If you have not yet met your deductible, part or all the cost of your brace may apply toward it.
Copayment (Copay)
A copayment is a fixed amount required by some insurance plans for covered medical services or equipment.
Coinsurance
Coinsurance is the percentage of costs you share after meeting your deductible. For example, if your plan covers 80% of a service, you may be responsible for the remaining 20%.
What If My Insurance Doesn’t Cover My Brace?
Some insurance plans may determine that a brace or service is not covered based on your specific policy or medical necessity guidelines. If your insurance does not cover all or part of your prescribed equipment, you are responsible for any remaining balance.
How Pricing is Determined
Pricing for orthopedic braces and durable medical equipment is determined by your insurance company’s contracted fee schedule with Synergy Orthopedics. After your claim is processed, your insurance company determines:
- The amount covered by your plan
- The amount paid by insurance
- Any remaining patient responsibility
Because every insurance plan is different, patient costs may vary even for the same type of brace.
Understanding HCPCS Codes
You may notice an HCPCS code listed on your insurance Explanation of Benefits (EOB).
HCPCS stands for Healthcare Common Procedure Coding System. These standardized codes identify the specific orthopedic brace or durable medical equipment that was provided and are used by insurance companies to process claims.
For many durable medical equipment products, these codes are established through Medicare’s coding system.
| Code | Description |
|---|---|
L4361, L4360 | A pneumatic (air-cushioned) or vacuum walking boot |
L3908 | A basic wrist splint that holds the wrist in a slightly bent-back (“cock-up”) position |
E0114 | A pair of underarm crutches made of something other than wood |
L3809, L3807 | A wrist-hand-finger splint with no joints |
L1820, L1821 | A basic elastic knee brace with hinges and extra padding around the sides of the knee |
L3670 | A shoulder immobilizer similar to a sling but usually includes a strap around the waist |
L1902 | An ankle brace/gauntlet, like a supportive lace-up or wraparound ankle sleeve |
L1830 | A rigid knee immobilizer (locks the knee straight, no bending) — the kind often used right after surgery or injury |
L1833, L1832 | A more supportive brace with adjustable hinges that let you set how much the knee can bend, used for people who can still bear weight and walk |
L4350 | A rigid stirrup-style ankle brace (the kind that wraps under the foot and up both sides of the ankle) |
L3260 | A surgical/post-op shoe (the flat, stiff-soled shoe you wear over a cast or bandage) |
L3660 | A figure-eight shoulder strap (canvas/webbing) that pulls the shoulders back |
L3923, L3924 | A hand-finger brace with no joints |
E0143 | A folding walker with wheels |
L3960 | An “airplane splint” that holds the arm out to the side (shoulder-elbow-wrist-hand orthosis) |
L0648, L0631 | A rigid lumbar-sacral brace covering a bit more area (tailbone up to mid-back, T9) |
L0642, L0627 | A rigid lumbar (lower back) brace with front and back panels, covering from the lower back up (L1 down to below L5) |
L3762 | A rigid elbow brace with no moving joints, just a firm shell with soft padding, to keep the elbow still |
E0100 | A basic cane |
L1812, L1810 | A basic knee brace with hinges but no padding at the knee |
L4387, L4386 | A non-air (non-pneumatic) walking boot |
Return Policy
Federal Law prohibits the reuse of medical supplies; therefore, returns of medical supplies are only accepted in cases of manufacturer defect within the warranty period for product. In addition, for health and hygiene reasons, products are not returnable or exchangeable once the packaging has been opened and or any evidence of the product being worn, EXCEPT for the reason of manufacturing defect.
RETURNS WILL ONLY BE ACCEPTED FOR:
- Unneeded products must be returned within 3 business days, in new (unused) condition.
- Unneeded returned products must be in the original packaging – this is a compliance requirement.
- Unneeded returns 3 days are accepted only for defects in material or workmanship. (An example of an “unneeded return” is a product that was prescribed for a patient having surgery and the surgery was cancelled.)
- Ineffective or poorly fitting product may be exchanged for a different modality or size within 7 business days.
*No product will be accepted for any return beyond 7 business days for any other reason EXCEPT for the reason of manufacturer defect and only under the conditions as offered by the warranty.*
